Jamie, I'm happy to respond to your question if that works. Good afternoon. Welcome to today's webinar on best practices for using blood volume analysis for BVA, or also known as BVA, to reduce heart failure, length of stay, readmissions, mortality, and cost. We're gonna be taking a closer look today at best practices for implementing BVA, which has demonstrated really improved outcomes and reductions in the total cost of care for heart failure patients, both hospital and ambulatory setting-wise. So during the webinar, you will see that there is a spot down here at the bottom of your screen for questions and answers. Please feel free to click on that and enter any questions you may have. Off to the left-hand side of the screen, you'll see the chat box. And in the chat box, you'll find a link to the presentation, as well as the recently published MedAxiom and Daxor Business White Paper on blood volume analysis. So feel free to click on those links so that you can have those resources available as well. So we are going to dive right in because we've got a lot of content to cover. I am just delighted to be able to share today's webinar with some terrific panelists. I'm going to start by introducing Dr. John Jeffries. Dr. Jeffries is the J. Michael Sullivan Distinguished Chair in Cardiology. He's also Professor and Chief, the Division of Adult Cardiovascular Diseases. He's a Professor of Pediatric Cardiology, LeBon, who are Children's Hospital, Professor of Department of Preventive Medicine, and a Research Member at St. Jude's Research, Children's Research Hospital. And somehow or other, he's also found time to be the Governor of the Tennessee Chapter of the American College of Cardiology. So a busy person, and we are delighted, Dr. Jeffries, that you've been able to join us today to address a little bit more about why optimal blood volume matters. So I'm going to hand over the podium to you and take it away. Thank you so much. And we have a few slides to get through, but we'll talk about these, and then at the end, we'll have some opportunities for questions from the audience. But first of all, thank you for taking time to join us today, and thanks for the opportunity to speak to you about a technology, which we think is transformative in how we manage heart failure patients. And I'm sure I'm preaching to the choir if I mentioned to everyone on here about the guidelines, 22 updates, obviously. And we know a few things in there that we recognize in our own minds, but I think the big question, the overarching mission about this particular, you know, delivery today is how are we getting at these things? And so we all know anemia is an important thing. You know, it's a comorbidity we're supposed to assess for and treat in the heart failure guidelines. And then obviously looking for additional causes or specific causes of heart failure should be explored. We know that that's a class one recommendation. And we know that in patients with heart failure, vital signs and evidence of clinical congestion should be assessed at each encounter to guide overall management. And part of what we're gonna talk about today is there a better way to do that? I think we all graduate from our programs, and if you're in cardiology, graduate from cardiology fellowship, feeling confident that you can assess volume status in patients. And I've been doing this for 20 years, and I think I can say confidently, we're not as good as we think we are on clinical exam and even leveraging typical biomarkers. So we'll talk a little bit about that. People that are hospitalized, obviously trying to assess the degree of congestion and adequacy of perfusion is something we all do. Are they warm or wet? Are they cold or dry? Those are all things that we try and look at. And then what are we trying to do that maybe gives us ideas of trajectories, right, about appropriate therapy? And to inform that, you really need to understand the volume status of the patient. And then ultimately, continuations and optimizations of GDMT always revolve around the idea of uvulemia, and that impacts things like blood pressure, use of diuretics, which have downstream effects on your ability to achieve GDMT, and obviously causing kidney dysfunction, AKI. So all important components we have to consider. Next. So this is just sort of reiterating a synopsis of what we just talked about, in that every attempt should be made to measure a no total blood volume. And I would propose to everyone today is that we really struggle with that in clinical practice. And so some of the things that we know we want to take away from opportunities in clinical care is could we optimize our detection of anemia? Because it really is under-detected and under-treated in heart failure for a variety of reasons. We know hematocrit is an unreliable method of defining anemia, and we'll talk a little bit about that. We know that the actual target should be red blood cell volume, and that should be measured. And the good news is that it can be measured, and we'll see some evidence of that. And then we really need to use that as a comparator in some way to total blood volume, and looking at how we can actually best inform our care and guide our care. And obviously looking at total blood volume, plasma volume, we'll talk about these compartments in just a few minutes. Next. So this is kind of probably an overarching theme of my segment of this talk, is the idea that pressure and volume are not the same thing. And these are some older data, 2008 and 2013. We have some more recent data than myself. I've participated in publishing. But this idea that we always walk away, think, well, if we look at a pressure, whether that's an intravascular pressure or otherwise, we give a good idea of volume, but it actually turns out they're really poorly correlated, as you can appreciate from the figure on the left. And you might think, well, okay, I'll just leverage my serologic biomarkers, right? And these are things we do in clinics every day, looking at things like BNP or antiproBNP, those are stretch-based hormones. And there are a lot of factors that go into how BNP, circulating level BNP, what does it really represent? But that being said, it actually turns out that BNP does not equal volume either. So these are the conventional ways we would approach volume in our clinical practices, right? Is it, maybe we would do a physical exam, maybe you have a patient that has some sort of pulmonary artery pressure monitoring, for example, and you do blood work. And so we're looking at these saying, well, this is giving us an idea of what the overall volume status of the patient is. And it turns out leveraging these particular biomarkers don't work. Next. So back to a little bit about just back to physiology and remembering where do we store fluid, right? As a human being, where do we keep fluid? And three main compartments, and you can appreciate here, majority, obviously, we have a lot in the intracellular space. 64% of our total body volume is going to be there. Next hitter would be the interstitial space. And we'll talk a little bit about the interstitial because obviously that's a place where you can hide a lot of fluid over time, right? And then lastly, the smallest component or compartment is the intravascular space. But when you're giving things like diuretics and rapidly trying to mobilize fluid, where are you extracting fluid from? Well, you're taking it from the intravascular space. Now, how we feed fluid into the intravascular space, a topic for another day, but remember trying to mobilize fluid from these other compartments may take time and it needs to be adequately assessed to say, well, where is the fluid actually at? That kind of gives you some ideas about how to unload the fluid. Next. So this is a little bit of an idea of where we are when we look at these different sort of silos for fluid containment. Obviously fluid moves in and out of all of these and in real time, and we can do things to influence that. But I think the main things you're understanding is that the capacitance of the interstitial space is very large, right? So you can get lots of extra fluid built up into the interstitium, but also remembering you can't really look at a patient and say, well, I know exactly how much fluid is each in one of these spaces by a clinical exam or even by some of the biomarkers that we've talked about. And what are the things that sort of influence all of this or some of the things that we're gonna talk a little bit more about is, one, how can you know where things are using an objective clinical tool, which is exactly what BVA is gonna provide for you. And then understanding that these are not absolute sort of rigid measurements, they change over time. And how could you leverage something like BVA to assess where patients are, but also see what they're doing along the continuum when you intervene. Next. And this is a great figure, I think, is this idea of where are we trying to be? And I think we all get this, right? When we're in practice, like, well, we want people to be euvolemic and that's exactly what we're going to accomplish. I would posit back to you, that's really hard to know where that is. And it's really hard to achieve. I mean, these are very dynamic processes, but we know that undershooting or overshooting volume can have important implications clinically, right? So hypovolemia, obviously tissue hypoperfusion, AKI hypotension, syncope, organ damage or considerations, but hypervolemia also has its own downsides. You can drive heart failure decompensations, you can accelerate disease processes, especially at the myocardial level, and you can lead to organ damage. Next. So this is just some ideas. We'll start talking a little bit about phenotypes when it comes to heart failure and how we look at volume and the underlying red blood cell volumes that are a part of this composite sort of report that you can look at. And understanding that we do shoot, let's say you have five liters that we're talking about and how much would we be looking for for an ideal red blood cell volume? But it's very easy for these things to get deranged and they're almost always deranged in the setting of heart failure. And so you can get an idea of some of these different representations in that maybe your plasma expands, you remain normal volemic, but you're actually anemic when it comes to red blood cell volume. Maybe you're hypervolemic and you have a normal red blood cell mass. All of these sorts of things happen that are really hard. They're shifting sands. And it's really difficult for clinicians to look at this just on basic blood work or clinical exam to really know what's going on. And you can imagine these different phenotypes have different treatment strategies. And some of these are gonna influence outcomes, especially those that are anemic, right? So identifying anemia accurately and then treating it. And you can appreciate here on the survival curve on the right, how much these things actually impact overall survival when you're dealing with true anemia as opposed to a delusional anemia. When we talk about looking at blood work to discover who is maybe potentially suffering from delusional anemia, I would say the way we do that in clinical practice is really not very accurate. And this gives you an objective way to do that. Next. This is a great paper from John Strobeck. And I don't wanna spend too much time on it. It's a lot of information to digest, but I would encourage you to read this paper if you can. It was a Jack Hartfeller paper about four years ago. Long story short, what you're looking at here are people, 245 patients that were looked at, and they were compared to sort of a matched analysis cohort to see what their outcomes would be. And ultimately what we saw is that using things like BVA actually lead to statistically better outcomes when it comes to 30-day readmission, 30-day mortality, and 365-day mortality. But an important component is that some of the breakdown of this is that when you look at these 245 patients, the majority of them were uvolemic or hypovolemic and anemic. And so remembering that anemia component is one that we wanna target, and then we wanna intervene on that, right? Because we know that influences outcomes. Next. Next. And that's just highlighting those data that we were talking about is these different phenotypes. And I wanna spend a little bit more time on that in just a second. So we know that BVA really does improve Hartfeller outcomes. And these are some of the data that John published in that paper that we were just referencing. So when you look at that, the cohort, that 245 patients, there were some people at EFs less than 40, greater than 40. So very heterogeneous group. And the point is is that regardless of that Hartfeller phenotype, leveraging BVA actually did make a big difference, as I said, compared to sort of a control group that was very similar longitudinally. 82% 30-day mortality rate, big changes there, obviously statistically significant. 56% change in 30-day readmission rate, 86% change in one-year mortality rates, all highly statistically significant. And if you think about it, remember back to your statistics training, 245 patients, that means the delta between these two is pretty robust, right? If you're getting those kinds of P values with this small of a cohort, that ought to tell you that what we're doing here is very impactful. Next. And once again, back to the heterogeneity of the phenotypes, I think this is something we see in clinical practice, but maybe we don't always appreciate. And the idea that how we approach patients as an individual by applying sort of cohort-based knowledge isn't always an exact science. And understanding that these patients here that were looked at, so you have a number of patients listed there on the left, total blood volumes were up in everyone, right? But you see this red line in the middle of that figure, you can see some people actually red cell mass is below what we would consider normal or target range, right? And some is above. So not everyone is fitting into this nice little discrete sort of corner of management, but also recognizing the plasma volumes are highly different amongst these different patients. And so it tells you, one size really does not fit all. And how could you use a test that's objective that targets the patient in front of you to inform their therapy? Next. This is just this back to this idea of looking at the conventional markers we would use in cardiology, right? From a hemodynamics perspective. And how well did they really sort of correlate with circulating blood volumes? And we would tell you it's very, very poor. And so what I'm saying to you today is, is that we don't wanna throw out all the other biomarkers that we use conventionally, right? But could we layer something on top of that that actually gives us the information we are asking for, which is volume, that is what we are asking about. And that's what this test can help us with. Next. This is just unrecognized sorts of opportunities and once again, the splay of data, which I think are just fascinating. And these are in some different reports. The Yeronova report was something that I was a part of, but you can see from Miller and Andron and Strobeck, pretty broad experiences, but see how much there goes on either side of zero, right? Very much in the negative range, deficits, right? Up to obviously excess and everything in between. And for me, it's pretty straightforward to say that across a variety of cohorts, right? So stable outpatients, ambulatory patients, but functional class two to four, hospitalized heart failure. And our report was in LVADs. Our conventional analysis of these patients fall short. And this is where BVA can help us. Next. These are the phenotypes that I wanna spend just a little bit of time on. I know I'm approaching the end of my segment, but this is how, if you were to get a report or pursue BVA, this is the way that we would want you to think about it because it, one, it characterizes the phenotype, but more importantly, it gives you a treatment strategy to deal with that phenotype, right? So hypervolemic polycythemic, the idea of phlebotomy, right? And we don't do this as much in conventional adult cardiology, unless you're maybe in the adult congenital world, as we do the other things such as diuresis. But all of these are hugely important because they all have important implications for treatment opportunities and for optimization, right? It's gonna be really hard to get these people to where you want them to be if they are polycythemic. Conversely, it's gonna be really hard to optimize the potential outcomes if people are anemic and not treated. Next. This is a, I apologize, it's a busy slide, but I think it conveys a fair amount of the momentum that is developing behind BVA. And so you can appreciate here a lot of the different reports that are out there. I've been very fortunate to be involved in the majority of these on this page, but telling you that there's a lot of science behind this, right? And by very prestigious centers that are participating in these things across a wide variety of patient spectrum. So whether we're looking at things like right ventricular dysfunction that Wayne has looked at, for example, how are we looking at these things in people with LVAD? So mechanical support patients. How are we looking at remote monitoring patients? All of these different things, I think, capture a pretty large part of the heart failure spectrum that we deal with in clinical practice. For me, the takeaway when I look at this is, is that BVA is agnostic, right? We can use it in a lot of different settings and use it very successfully in a way that actually impacts how we treat patients over time. Next. So my own personal experiences have been involved in BVA with a lot of different opportunities and we think all successfully. So we here in Memphis, I've been involved in standups for BVA and two healthcare systems, interestingly, both competing healthcare systems. And one has driven a lot of the outcomes data we're talking about, especially in those LVAD patients. The other is more of in the startup or acceleration phase. But we would say both these systems, and this is gonna be true of anywhere in the United States or even globally. Every hospital has a different administrative approach, a different clinical delivery, different set of metrics that they care about, different patient populations, different geography. My point is we'll be able to do it in both and do it successfully. One system, as I said, is very far down the path. We've driven a lot of favorable decision-making in our patients. It really is making a difference in how they're doing, not only objectively with biomarkers and those sorts of things, but subjectively meaning how they feel. Second system is still very much on the upward part of the curve, but really starting to understand some of the economic benefits, I think, which is always an important component of these discussions. And you'll hear about some of that later, but also just the ability of becoming familiar with the technology and how we can implement it in everyday practice is becoming easier. And interestingly, the second system is actually learning a bit from the competitor system across the way. So there are opportunities, I think, to make everyone better as a part of this process. Next. So with that, I appreciate your time. Thank you, Dr. Jeffries. Our next speaker is Dr. Tim Manzoni. He has served as the Medical Director and Section Chief of Nuclear Medicine at Christiana Care Health System. This system was the first facility in Delaware to perform a semi-automated blood volume analysis and has performed several hundred clinical BBA studies. He's also served as the President of the General Clinical Nuclear Medicine Council with the Society of Nuclear Medicine. Thank you, Dr. Manzoni, for being with us today. Well, thank you for having me. I'd like to talk about the nuclear medicine perspective for blood volumes. If you believe that volume is inextricably intertwined with heart failure and that volume is really what you're going to be treating, then it's got to help to actually measure what you're dealing with. And that's where nuclear medicine comes in. Nuclear medicine techniques have been the gold standard for measuring volumes for many decades. Nuclear medicine blood volume studies go back a long way and they use the indicator dilution technique, which means basically measuring a volume by taking a known amount of small amount of a tracer, mixing it into a big volume, and then taking a sample and calculating the volume from how diluted it gets. With the traditional gold standard blood volume technique, there was, it was pretty complicated to do. It used two different tracers. One of the tracers that is, was used, it's no longer even available and it was tricky. It took a long time. It required calculations and mixing and plotting and very complicated. So we've really come a long way, but nuclear medicine is still the way if you do want to measure volume and know for sure what it is, that's the way to do it. Next. So let's look at the modern BVA. The evolution in the technique has made it accurate, accessible to more nuclear medicine departments and also clinically accurate. The accuracy is provided by the technique being semi-automated. There is no mixing. There are pre-packaged unit standard doses. That's a little syringe that you see. The standards, you don't have to make them yourself anymore either. Those are the vials that you see there and they come with the doses. So there is no calculation. There is no plotting. And it's really pretty, pretty straightforward. The heart of the system is the machine that you see in the center, which is a computer controlled gamma counter, which does all the counting automatically once it's started up. And one of the things that makes today's BVA particularly actionable is that the results of the study also include individualized norms for total blood volume, total blood volume, plasma volume and red cell volume so that you can tell for each individual patient how far they deviate from what would be considered ideal. Earlier versions of blood volume measurements didn't have the norms. So the results, although they were potentially very accurate weren't nearly as useful as they were today. So today's test has a lot of differences. Next slide. We do use a radioactive dose. That's why it's done in nuclear medicine. The tracer that we use is iodine-131 labeled human serum albumin. It's about 25 microcuries, which is really a very small doses as these things go. And just to get the radiation exposure issue out of the way, the exposure that a patient would get from a BVA study is about a third of the annual background, maybe about a hundred millirem or 0.1 millisieverts and a small fraction of what they would get from a nuclear cardiac stress test or a CT. So that really should not be a particular concern. Next. So let's look at how the test is actually done. The test can be really divided into two parts. The first part is the tracer administration and the sample collection. And that covers the first line on this diagram up to the three red test tubes. This part of the test can be done at the bedside. It can be done at the point of care. It can be done in the nuclear medicine department, really whatever is convenient. An IV needs to be established. The tracer is administered. It's, as I said, a unit dose that's designed and patented to deliver exactly what it's supposed to deliver. There's then a 12 minute tracer diffusion period that you just wait. That is to allow the tracer to diffuse throughout the vascular compartment. And so there's a uniform concentration of the tracer. And then several sequential blood samples are drawn about four or five minutes apart. That is because you need to calculate for what's called albumin transudation from the vascular compartment. You need to have some sequential samples so that you can generate a time activity line. It actually doesn't matter the exact timing of the drawing of the samples, provided the time that you actually do draw the samples is accurately recorded. The samples are then taken back to the nuclear medicine lab for processing. So this is the first part of the test. This takes half an hour to 40 minutes, give or take. If the care staff is all on the same page, it makes things go much more smoothly, but we'll figure about half hour, 40 minutes for this first part of the test. The second part of the test is done in the nuclear medicine lab. The samples are centrifuged to separate the red cells in the plasma. Some samples of the plasma are then pipetted out to the, put into tubes, which are then placed in the machine. And then you push the button and the machine does the counting. Centrifuging and preparing the samples for counting takes probably about 15 minutes or so. The counting itself takes maybe half an hour or so. That's sort of walkaway processing. The technologist doesn't have to watch the machine for that time and can actually do something else. Then at the end, the machine generates a screen, a printout that gives the technologist an opportunity to do a little bit of QC. The samples are counted in duplicate so that any pipetting errors can be caught. You can, there's a certain amount of QC to make sure the study is most accurate. And then the report can be printed out and sent back to the clinicians. Overall, the study comes out about 98% accurate. And in our experience, it's pretty robust. There are not nearly as many things as can go wrong as there used to be on previous studies. Another option for some institutions may be to do the first part of the study, the tracer delivery and sample collection, collect the samples and then send them out to a reference lab where they can do the counting. So that's an option. There's about a 24 hour turnaround time for that. But it's not that challenging to do the whole thing in a nuclear medicine lab. Next. So in our experience at Christiana Care, we brought the BVA test in because I got excited about it. I was unhappy with the accuracy with which we were doing our blood volume studies and with the nuisance that it was. And I realized that this would be a better way to do it. I also realized that a test that could actually tell us a patient's volume status and could potentially help with all those, is the patient wet or is the patient dry, discussions that we all had through medical school and residency would have to be a very powerful test. So we brought it in and then the clinicians started to use it. The considerations that nuclear medicine is going to have when considering whether to offer this test is that they need a place for the BVA 100 machine. It's not that big, about a two, three foot box. They need to store their doses, which there will be a facility for that in a standard nuclear medicine lab anyway. The technologist time to do the test, we reckoned on about two hours. It's actually probably a little bit less than that. As I said, the first part of the test takes about half an hour to 40 minutes. And then the counting, the technologist can do other things while the samples are counting. So, and it doesn't have to be the same technologist anyway, it can be handed off among the staff. The nuclear medicine department will have to have a radioactive materials license that covers I-131 in tracer doses. As I said, the dose is 25 microcuries. So it's very, very small. And a CLIA certification for this test is currently required. It's not a waived test from a CLIA point of view. There are ways to do this, either with partnership with the hospital's clinical lab or the nuclear medicine department can get its own CLIA certification or ways to address that. So for nuclear medicine, it's really an excellent opportunity. The reimbursement for this test is pretty good, especially in the outpatient setting, depending on how you code it. And there's guidance on that. And it really is an opportunity for nuclear medicine to assume a really vital role in day-to-day patient care and improve outcomes for the institution. Nuclear medicine, except for PET imaging, has not had many new, exciting, impactful things happen. But this is an opportunity for nuclear medicine to really get in there and be involved in giving information that actually does impact care. So part of my advice would be to engage a champion from the nuclear medicine team and have that individual partner with the clinical team to figure out how best to get this going. You will need to develop workflows to ensure the best clinical impact. And there are lots of different ways to do this. It can be worked into the EMR system. It can be and should be really worked in order sets so that getting the BPA doesn't fall through the cracks. And there are resources to help you do that. The MedAxium-Daxor white paper has a wealth of information and best practices. And Daxor is also used to help work out workflows and get the thing going. So from my perspective, as somebody who's done lots and lots of BPAs, it's a tremendously powerful technique. It's really quite doable. It's accurate. It's quite robust and gives nuclear medicine a great opportunity to help improve outcomes. Thank you. Thank you, Dr. Manzoni. Our next speaker is Jim Kreiner. He is the director of the cardiovascular operations at Prisma Health Heart Hospital Midlands. He has oversight for the cath lab, EP, cardiac and vascular imaging, cardiac rehab and the advanced heart health center that includes heart failure, bowel and LVAD clinics. Thank you, Jim. Okay, thank you. Good afternoon, everyone. Go ahead and advance to the next slide. My goal today is really gonna be to tell you kind of our journey or our story with related to blood volumes. And to start out just to give a background of Prisma Health here in the Midlands. We're a level one trauma center with 541 licensed beds. And we're fortunate enough to have really a dedicated heart hospital that is 124 of those beds. Solely dedicated to the heart care. And 20 of those beds, we're also fortunate to call our heart failure clinic. I mean, our heart failure unit. It's an accountable care unit. We try to track all our heart failure patients to this unit. And they do a great job. It involves multidisciplinary bedside rounding with the patients. And one of the probably the biggest factors is we have kind of a really strong dyad clinical leadership as well as operational leadership. To support this unit. We also have a hospital based LVAD and heart failure clinic. It's literally right below on the first floor of the heart hospital. And we probably, we do everything at Richland up to transplant. We have a fairly robust LVAD program. We probably do about 30, 35 LVADs a year. And it's probably, we also do, and I'll talk a little bit about it, but we also do BVAs on our LVAD patients as well. Go to the next slide. So when we look at our journey to kind of where we are today, Dr. McCann, one of the heart failure cardiologists got really interested in blood volumes and we had a lot of hurdles we had to work through. At that time, the only analyzer we had was at one of our hospitals, probably about two miles away. And honestly, it was new to the nuclear medicine department here on the Richland campus. And so we had to get training. We had people kind of couriering stuff back and forth. And ultimately it really was kind of a fragmented process that didn't work the best for our providers. And so probably in the early, or the beginning of our journey, that was one of the toughest parts to really maximize BVA like we were wanting to. In probably 2020, we got together with our nuclear medicine team, our providers, and really said, you know, we got to figure out, we see the value in BVA, but we got to make it easy. That way we weren't delaying getting the tests done, turnaround times. And that process included also getting BVA added to our CLIA license on this campus. So once we moved the analyzer over to this campus, I will tell you, that's probably when we were able to maximize the analyzer the most, as well as with the current nuclear medicine team that we had on the Richland campus. Next slide. So kind of current state where we are with blood volumes, we have two analyzers. They currently are both on this campus and we have done a really good job streamlining the process the best we can. The communication between the providers and the leadership and the nuclear medicine technologists is really, really good. I think that's important to ensure that the process is quick, easy, they get the results in a timely manner and ultimately for the patients to get the results that they need and the providers to get those results in order to treat them the way they need to. Probably about that same time, we developed the plan to get the analyzer over here. We also started a heart failure care redesign team. This was a system-wide initiative with our partners in the upstate and all of the advanced heart failure docs. And it's probably been what led to us organizing and streamlining our heart failure order sets. I feel like that was probably, it was a long process, but at the end of the day, I feel like the product that was created in the collaboration with the upstate has allowed us to get fully embedded heart failure order sets for admission and discharge that has also allowed us to add BVA to that process. Before that, it was out there and really just the providers, the advanced heart failure providers were aware of the test. But as part of the heart failure redesign, probably in the October timeframe, we also added our hospitalists to the process and the committee and really started pushing for readmissions, mortality, and length of stay for this population of patients. After that, we got the order sets live. We also are working with our ED patients coming in where our goal is to try to figure out a way to not admit the patients. And BVA has been a part of that process. We get the test ordered, get the results back, and it allows the advanced heart failure docs to decide, where's the best spot for this patient? Can we discharge a patient and see them in the clinic? Do we need to put them upstairs? So that collaboration with the emergency room has been good. They have the ability to do a direct consult to advanced heart failure. And then we streamline the test for the BVA test there as well. Next slide. This is just a small example of what it looks like in the order set. This is just the blood volume piece of it, but we're currently in the process of streamlining it. Before, we were really doing blood volume tests for different reasons. And with the focus now, I would say a majority of the tests that are ordered now are by our heart failure physicians for our heart failure patients. And so we are in the process of updating the indications or the common indications like volume overload, trauma shock, decompensated heart failure, things like that. Next slide. So this is really probably what drives myself and the providers the most is, what are the outcomes, right? We do all this work. And I would tell you that to kind of follow the graph, it's a little bit busy, but it tells a lot of information. The green line is kind of where CMS targets for heart failure readmissions, which is 14.8%. The kind of orange line is what our readmissions look like prior to really finalizing the order sets and also incorporating BVA into those order sets. Kind of the gray line is order set utilization. I would tell you an important piece of this is tracking the data to, you build order sets, but the important part is, how do we get the providers to use them? Not just the advanced heart failure docs. How do we get general cardiology to use them? How do we get a hospitalist to use them and embed all these tools to ensure that we are doing the best practice for our heart failure patients. And you can see clearly as our order set utilization went up, our overall readmissions significantly went down. And so we had a fairly drastic, we were only at about 12% order set utilization. We pushed that up closer to 50. And with that, you can see our heart failure 30 day readmits. We were tracking around 20, 21% and we're down in the nines. I would tell you probably today, we're hovering in the 11% range, which kudos to the team. They've done a phenomenal job embracing the order sets and making sure that the patients are getting what they need. We've seen decrease in length of stays. I think Dr. Jeffrey's slide showed that. You see the decrease in mortality, decrease in readmits. And we definitely, during this process, when we embedded the BVAs into those order sets, we saw a pretty dramatic increase in the utilization of the BVA test. And it was a probably increase about 100%. So ultimately, give kudos to my team for all the hard work. We did have one quarter, which we were top decile and linked to stay mortality and readmits, which we're very proud of. Obviously, that's tough to consistently do. You can kind of see in the chart, you're gonna get spikes or months where you are gonna increase in ebb and flow and readmits. But at the end of the day, our goal is to kind of keep them down, which we've been able to do. Next slide. So in summary, I would tell you, our best practice are related to blood volume analysis. I recommend getting with your physicians and creating a very solid order set that becomes standard. I think that that's what we did in incorporating BVA in those. It's a tool that needs to be part of the toolkit in order to really drive down mortality and readmits and link to stay for this population. Try to get the BVAs. Our physicians have learned that the earlier they get those BVAs in the admission, the quicker it's gonna help them understand what they need to do to help the patient, get the patient out of the building. And probably one of the things I definitely wanna drive home is, we can't do this without our nuclear medicine team. We've got strong leadership down there. They embrace this when we were really pushing this test and probably the day-to-day communication of results and ensuring that it gets back to the provider as soon as possible has probably been one of the bigger successes as part of this as well. One thing I do wanna throw out there is strong clinical leadership. And our nurse manager for the heart failure unit is also the nurse manager for the heart failure clinic. That has been a big piece for the transition of care from inpatient to outpatient. She fully gets it. And it's one of those where it's hard to do. That's a tall ask for a manager, but she's done a phenomenal job in making sure that transition is what it needs to be. The CLIA piece, I would tell you to get that started early. I mean, in order to get BVA going, that's where we are with the upstate getting nurse, they've got their unit and getting them started. We're really close to them. Having BVA in that hospital as well, we're exploring getting a BVA unit, even in a smaller hospital where we have a lot of heart failure patients in that community. So next slide. Okay, I'm gonna hand it back to Denise. Yeah, good. Thanks so much, Jim, for that tour de force here. I see that we've actually got a couple of questions in the Q&A. The first one, Jim, I'm gonna pose to you because you mentioned that you just had purchased another analyzer. Someone's wondering how much the analyzer cost. I definitely would recommend getting with Daxor on that piece. I wanna say the analyzer is between 70 and 80 grand. I'm going off of memory here, but ultimately I would tell you, it's kind of, I think it's important for the administrators if we've got any on here that to understand the test, I think the providers got me heavily involved in understanding really how it benefits the patients. The, you know, these are, again, I go back to one of Dr. Jeffrey's slides about mortality. And I mean, these are patient's lives here. And getting the, I was sold pretty quick on the technology, but as an administrator, there's ways to prove the need. And whether that's cost avoidance with decreasing readmits, length of stays, or the, there is margins on the outpatient side that can help cover the expense, so. Yeah, good. Thanks for that. Dr. Jeffrey, so I saw you nodding your head there, a little bit from that clinician standpoint, justifying to the administrator as to why and how. Yeah, I think, you know, we need to be sensitive as clinicians. You know, obviously we all agree that we're here for the patients, right? That's why we do what we do. And if you can impact outcomes, that should be the target of how we approach this. But we also need to be sensitive to the economic realities of hospitals and hospital systems. And I think that's where a dyad sort of conversation is hugely important. And on the physician side, just trying to provide objective data that can really show these sorts of outcomes and impacts. And those have downstream effects, right? Whether that's changing readmission penalties, as you've heard, that's opening up beds for other patients that need them. All these sorts of things are important considerations. So I think more than anything, just starting the dialogue armed with these data sets will be very helpful for anyone trying to stand up a program in their institution. Jamie, do you want to, just in terms of from a nuclear medicine standpoint, I know that's your background as Dr. Manzoni, that's where you've lived for many years. Maybe just a question there, just some further investigation about what it means for nuclear medicine department and practicalities. Yeah, I would address that question to Dr. Manzoni since their lab has been doing this for a period of time. And what advice would you give for a nuclear medicine lab that was just starting out? Any best tips? I think that for a nuclear medicine lab, one of the important things is to understand this test, understand how it works and understand how important it really is. I think that one of the secrets of success to have this work is for the people who are going to be using the test results to really believe in it and make a commitment to use them. One of the things that you have to remember is that BVA tests are going to give surprises and you're going to find out that patients aren't what they're clinically suspected to be. And I think it's important that people realize that the test is going to give you an accurate measure of intravascular volume status and that it's not really just another of the surrogate markers, it's really the answer. So you have to be prepared to act on those surprises and follow the results and then be consistent, incorporated into order sets so that it becomes part of the routine. Really good point. I think it's those clinical surprises when we think as clinicians that we know what's going on and then to find that something like this really reframes the conversation can sometimes set you back with a little bit of disbelief. Dr. Jeffries, would you comment then just a little bit about how you've helped the cardiologists in your institutions address that and kind of believe the results, if you will? Yeah, I think it's been a process to be honest, especially for people aren't as familiar with the technology. I think cardiologists don't typically lack in confidence. So their considerations of volume status are right until proven otherwise, right? And that could be from 40 years of experience or four years. So I think a lot of it's really just being armed with objective information and that's where that list of all the publications has been very helpful, I think, in creating a compelling argument. Yeah, great. You know, we have one other question in the Q&A. I think it may have been pretty much answered and I'll let any one of the panelists address this. I'm wondering how BDA in the order set is stated. And I think, Jim, your slide gave a nice example for what that looks like. That's an epic system. And wondering if it's for all patients on discharge or just certain patients or any particular day in the hospitalization. So Dr. Manzoni or Dr. Jeffries, would you like to address the when and the who? Well, I think that there are multiple places that BVA can be worked into the system. One of the considerations is that if the test can be done on an outpatient basis, the revenue generated is more favorable for the nuclear medicine department than if it's done as on an inpatient basis. But I think the important thing is to develop a workflow that works for the individual institution. And as Dr. Jeffries pointed out, if it's an inpatient thing, get it done early so that you get as much of a jump on knowing what you're going to be doing as you can and then be consistent about it. Maybe Dr. Jeffries can have something to add. No, I agree completely. I think those are one of the things that we've learned through sort of our evolution of the use of the test is earlier information usually is going to impact things downstream more favorably, including length of stay, obviously. So those are things we would tell you to take advantage of. Yeah, great. Well, given that our time is growing short, I'm just going to move us along. We've got a couple of just closing shots, if you will, summarizing today's discussion, which I think it's been really interesting. I think it's enlightening. It's bringing awareness to the fact is that we've been working for a long time caring for our heart failure patients without maybe the full spectrum of understanding as to the various phenotypes that are out there. And that understanding that we've got better information, we can really drive that quadruple aim for improving those quality components. And those are patient-related metrics, right? That's reducing length of stay in the hospital, reducing hospital readmission, and then certainly reducing mortality that we've seen, as Dr. Jeffries pointed out. So those are the key elements that help us to guide more precision management of heart failure that we've not had for some time. And in the end, then really saving those valuable resources that can be diverted for better patient care. A little bit of a question was not asked, but just to let you know, in terms of reimbursement, there is robust reimbursement. As Dr. Manzoni pointed out, it is a bit more favorable on the outpatient side, your inpatient reimbursement is wrapped up in the DRG. So if anything else that points to the importance of making sure you've accurately coded and identified your patient when it comes for identifying the type of heart failure patient you have or the true nature of the patient's presentation. With that, what I would also just point you to is that Dexor has a tremendous amount of resources for you to take a look at. If you go to the link that's highlighted here on the slide and that you can download in the PDF on the chat, you can find, again, just a tremendous variety of resources. There's also, like I said, the BVA white paper that's included in your chat, all of which can help guide you and your clinicians to being able to operationalize and then actually utilize BVA for caring for heart failure patients. And then one last promotion coming soon will be a clinical toolkit, Dexor's sponsoring with MedAxiom's production that will really outline all the steps you need for implementing BVA in your institution and with your clinicians. So a ton of really tremendous resources coming your way, already available, are outlined for you here as well. So with that, just thank you so much for joining us today. The recording of today's webinar will be available in the next couple of days on the MedAxiom Academy. So if you have some of your colleagues that wanted to join but were unable to join, they can pull that recording down, access the resources, and understand more about the value that BVA can bring to your patients. So with that, thank you. Have a great rest of your afternoon, and I look forward to future webinars with us here at MedAxiom. Have a good day.

blood volume analysis

heart failure outcomes

length of stay

readmissions

mortality

cost

best practice

clinical decision-making

early testing